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Referred By
Practice Settings Retail
  Clinic
  Hospital
  Mail-Order
  Home Infusion
  Long Term Care
  Institutional
  Pharmaceutical
  Nuclear
   
Department Inpatient
  Outpatient
  Satellite
  Consultant
   
# of patients / beds
Current Census
RXs filled / day
# of RPhs on staff
# of techs on staff
Prepare meds RPh     Tech
Meds prepared IV      Oral     Both
If IV's are prepared, what kind? AB
TPN
Chemo
Hyperal
IV to PO conversion Yes      No
Renal Dosing Yes      No
Cart fill Yes      No
Automation

Pyxis
Automed
Baxter
Abbott
Mckesson
Other

Mixing Machine

Baxa
Abbott
Manual
Other

Computer
Pharmacy Hours
Shift 1 Hours Shift 2 Hours Shift 3 Hours
   
Specialties
Acute Care Aids/HIV
Ambulatory Care Cancer Care
Cardiology Diabetes Educator
Geriatric Infectious Disease
Intensive Care Managed Care
Med/Surg Neonatal
Nutrition Obstetrics
Oncology Operating Room
Other - see notes Pediatric
Pharmacokinetics Rehabilitation
   
Alternate Contact 1
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